Fresh from a Pilates class, I’ve looked at the new Cochrane evidence on Pilates for low back pain and asked Chartered Physiotherapist and Pilates teacher Jane Callaway to explain more about Pilates and to share her thoughts on the evidence.

Back pain is a very common cause of disability and absence from work

I went to my first Pilates class in over a decade last night. It reminded me that signing up for a class can give me the nudge I need to go and do some exercise when I’m not feeling like it and that it’s a sociable business; I smiled at several people I recognised from somewhere (where?!) and just hoped I wouldn’t be called on to remember their names. I hadn’t bargained on agonising cramp in one foot from the moment I put my foot on the mat and I’d forgotten that I rely on lipreading and would be unable to follow verbal instructions from our sideways/upside down positions. I had more excuse than most for allowing my mind to wander off onto plans for the weekend, whether I might be feeling a bit hungry and how near we might be to the bit at the end where you’re allowed to just lie there (I think I did that several times before we were supposed to).

It was good timing, anyway, as I’d been looking at new research on Pilates. I’m lucky not to be one of the many who suffer from non-specific low back pain (LBP), a major cause of disability and absence from work. It has been estimated that 40% of people with acute LBP will still have it a year on and, of those, 60% will still not have recovered a year after that.

Exercise is often recommended as a way of managing chronic LBP. These recommendations are supported by evidence for the benefits of exercise in general, but reliable information about the effectiveness of different types of exercise would help people make choices about what to try.

Now, a new Cochrane review has brought together the best available evidence on Pilates, which is being increasingly used by people with LBP. The reviewers were interested in the effect of Pilates on LBP in terms of any outcomes that could be considered patient-centred, rather than physiological measures such as muscle endurance or range of motion. But first, what is Pilates?

What is Pilates, and why do it?

Pilates: aims to improve muscle strength, joint movement and balance

Jane Callaway, a physiotherapist who teaches Pilates, explains:

“Pilates is a series of exercises aimed at improving muscle strength, joint movement and balance of the whole body, not just the back.

Strength, mobility and balance are needed when doing sport and leisure activities, as well as everyday living such at washing, dressing, shopping, working and being able to sit/stand with ideal posture.

People with back pain sometimes avoid moving and doing exercise due to the fear of making things worse, which can quickly result in the loss of muscle strength and joint movement. This in turn will have a negative impact on their overall health and wellbeing.

Pilates exercises can start at a very low level, for example : concentrating on the breath whilst holding a static position, and progress to a much higher level of exercise requiring repeated maximum muscle contraction and combined balance work.

The role of a physiotherapist is to help educate people about why they have ongoing pain, help alleviate any fear associated with movement, correct any poor movement habits and postures, and teach ways to improve how the body performs at home, work and in sport.

Being able to move more easily will help people to do activities to maintain and improve their overall health and wellbeing, for example prevent/treat cardiovascular disease, diabetes and obesity.

A physiotherapist will work with the patient to ensure the correct level of any exercise is given, and made harder as the body responds to the exercise, which can start after just one repetition. The exercise given may be Pilates but currently depends on therapist and patient preference for this form of exercise.

Sharing research findings is vital to ensure evidence based treatments are offered whenever possible. Cochrane reviews help therapists and patients to know what treatments work well and what doesn’t, and ultimately helps them make an informed decision about their care.”

What does the evidence say?

The evidence in the Cochrane review comes from 10 randomized controlled trials with 510 people with non-specific chronic LBP. Six compared Pilates (led by trained therapists) with minimal/no intervention and four with other exercises. Treatment programmes lasted between ten and 90 days and follow-up varied from four weeks to six months.

Pilates is more effective than minimal intervention for improving pain, disability, function and global impression of recovery at short-term follow up and these improvements are seen for pain and disability at intermediate-term follow up

Pilates is probably no more effective for pain and disability than other forms of exercise

How reliable is the evidence?

The evidence was judged to be low to moderate quality. Whilst most trials were at low risk of bias, they were small and there were not many of them. None of the trials followed up participants over a long period of time. The reviewers note that there was research reported in eight conference abstracts but not in full publications, which could not be included in the review, and as unpublished studies are more likely to report negative findings the review’s conclusions may be over optimistic. Future research might give a different picture.

Where does this leave us?

Jane says:

Evidence suggests Pilates may be helpful but no better than other types of exercise

“The conclusion of this Cochrane review is that there is not yet enough robust research to provide evidence for or against the use of Pilates for ‘non-specific low back pain’. What evidence there is suggests that Pilates may be helpful but is no better than other types of exercise.

People with low back pain that do pilates on a regular basis often experience less or no pain but as yet there is no direct evidence that it is the specific Pilates exercises helping to reduce pain levels. There are many other factors that need to be considered such as the delivery style and skill set of the physiotherapist, whether the exercise is delivered as a class or 1:1, whether the patient has to self fund the exercise or not. It also needs to be remembered that for any exercise to be beneficial it needs to started at the right level for the individual, and be repeated on a regular basis.

Further research is urgently needed to help patients with non-specific low back pain, and to help identify which specific aspects of therapy help most with reducing their pain, and improving their health and well being. Back pain is an enormous cost to the western economy and therefore needs to be a priority for future research funding.

In the meantime Pilates taught by a physiotherapist is helping some patients manage their back pain and so it appears that continuing to offer this service is still appropriate in the light of this latest Cochrane review.”

About Sarah Chapman

Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients.
A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

As somebody who has never done pilates, but who has heard those that do talk about it in some mystical way that it’s the best and only way of exercising, and who tell me you can’t understand until you’ve done it yourself; I have found this an interesting read.
I’m sure the significant comment is that if you have any sort of pain you really should be working with a physiotherapist on a one to one basis, it’s important to avoid more damage of course, and general pilates may not be the answer, although if you are pain and injury free a general class may be useful.

This is a great article! So many people think it’s best to lie down and restrict movement for back pain. Now, evidence says that can be detrimental to recovery. Getting some exercise helps strengthen the muscles of the back. I don’t think any one particular type of exercise like pilates can be seen as a back pain cure. Many types of exercise are beneficial.

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